Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01618-198 | Inconsistent Implementation of VHA Oncology Program Requirements Due to Insufficient Oversight | National Healthcare Review | ||
1 The Under Secretary for Health ensures the establishment of Veterans Integrated Service Network-level multidisciplinary cancer committees.
2 The Under Secretary for Health ensures Veterans Integrated Service Network staff submit an inventory of available oncology services and facility points of contact to the National Oncology Program Office annually.
3 The Under Secretary for Health ensures complexity level 1 and 2 facilities pursue membership in the National Cancer Institute’s National Clinical Trial Network or the National Cancer Institute Community Oncology Research Program.
4 The Under Secretary for Health ensures the establishment of facility-level multidisciplinary cancer committees, or partnering with another facility or Veterans Integrated Service Network to provide the required committee functions.
5 The Under Secretary for Health reviews the operations of oncology-related program offices to ensure the required oversight of Veterans Integrated Service Network and facility oncology program implementation.
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| 24-01457-114 | VA Can Strengthen Appeals Processing and Tracking by Improving Caseflow Program Management | Audit | ||
1 Evaluate whether VA should establish an enterprise-wide governance structure for Caseflow development, consistent with VA’s initial comprehensive plan to Congress.
2 Develop a well-defined roadmap for the future development and implementation of Caseflow.
3 Enforce contract requirements through improved oversight, ensuring violations are identified and remediated.
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| 24-02154-154 | Facilities Faced Challenges Retrieving Medical Records from Community Providers and Importing Them into Veterans’ Electronic Health Records | Review | ||
1 Evaluate which staff should have access to and should update the Consult Toolbox when records are requested or received and update the “Consult Business Rules and Uses of the Consult Package Standard Operating Procedure” to reflect necessary changes.
2 Include controls within the Consult Toolbox to prevent errors and improve data quality, including controls on administrative closure of low-risk consults and documenting the records-retrieval method.
3 Update consult closure policies and procedures to clarify requirements for administrative closure and determine whether metrics for the percentage of records received should be a requirement and included in policy.
4 Determine whether Veterans Health Administration facilities’ community care offices should continue to be required to use the administrative closure report for oversight of administratively closed consults, and if not, determine what reports should be required.
5 Evaluate the workload of community care staff to determine the most efficient way to structure and execute their duties.
6 Determine if there are mechanisms to identify standardization opportunities and increase efficiency for improving records return processes.
7 Ensure community care staff follow procedures to reduce duplicate records received.
8 Evaluate ways to increase use of provider electronic records portals to reduce reliance on electronic fax when retrieving medical records.
9 Consider increased implementation of technologies to improve records processing once received to reduce the manual renaming of electronic files and uploading of records into the electronic health record.
10 Ensure records from the Joint Longitudinal Viewer are uploaded into the electronic health record.
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| 24-03417-188 | Healthcare Facility Inspection of the VA Spokane Healthcare System in Washington | Healthcare Facility Inspection | ||
1 The Medical Center Director ensures staff store clean and soiled utility items separately, maintain cleanliness, and dispose of expired items.
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| 24-00193-186 | Leaders Did Not Adequately Review and Address a Dental Hygienist’s Quality of Care at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.
2 The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.
3 The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.
4 The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.
5 The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.
6 The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.
7 The VA Southern Nevada Healthcare System Director educates the Chief of Staff on the need to complete management reviews when warranted, ensures that a review occurs of the dental hygienist’s care of Patient C, and ensures disclosure is provided if warranted.
8 The VA Southern Nevada Healthcare System Director makes certain that the Chief of Staff utilizes high reliability organization principles and establishes a process for the communication of pervasive concerns regarding a provider’s care.
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| 24-00605-182 | Healthcare Facility Inspection of the VA Cincinnati Healthcare System in Ohio | Healthcare Facility Inspection | ||
1 The Director ensures staff correct deficiencies found during comprehensive environment of care rounds or develop an action plan to address them within 14 business days.
2 The Director ensures staff conduct fire drills once per shift, per quarter, in each patient area.
3 Executive leaders ensure staff inspect all medical equipment timely, and equipment has preventive maintenance labels.
4 Executive leaders ensure staff properly clean patient care areas in the Emergency Department.
5 Executive leaders ensure staff keep exit pathways free from obstructions.
6 The Director ensures staff develop service-level workflows for the communication of test results.
7 The Director ensures staff implement a facility-wide process to monitor providers’ communication of urgent, noncritical test results to patients, and report compliance to an appropriate oversight committee.
8 Executive leaders ensure staff implement actions from root cause analyses timely, monitor actions for effectiveness and sustained improvement, and report compliance to an appropriate oversight council.
9 The Director evaluates the patient safety program, including staffing, to ensure executive leaders receive meaningful patient safety information and improvement project data.
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| 24-00593-181 | Healthcare Facility Inspection of the VA Central Ohio Health Care System in Columbus | Healthcare Facility Inspection | ||
1 Facility leaders implement a standardized process for service-level communication to consistently disseminate information.
Closure Date:
2 Facility leaders ensure Environmental Management Services staff keep patient areas clean and walls intact to minimize the spread of infection.
Closure Date:
3 The Medical Center Director evaluates the allocation of resources to ensure the Housing and Urban Development–Veterans Affairs Supportive Housing program meets the needs of the veterans served.
Closure Date:
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| 24-00395-179 | Inspection of Select Vet Centers in Midwest District 3 Zone 3 | Vet Center Inspection Program | ||
1 District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
2 District leaders and the Des Moines, Sioux City, and Kansas City Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
3 District leaders and the Des Moines, Sioux City, Kansas City, and Rapid City Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
4 District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
5 District leaders and the Kansas City and Rapid City Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
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| 24-00393-180 | Inspection of Select Vet Centers in Midwest District 3 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Detroit, Escanaba, and Cincinnati Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
2 District leaders and the Fort Wayne, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
3 District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
4 District leaders and the Fort Wayne, Detroit, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
5 District leaders and the Escanaba Vet Center Director determine reasons for noncompliance with annual fire or safety inspections, ensure completion, and monitor compliance.
6 District leaders and the Fort Wayne, Detroit, and Escanaba Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
7 District leaders and the Cincinnati Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.
8 District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with having a current emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
9 The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to inconsistencies in frequency for risk and vulnerability assessments and updates the administrative site visit protocol as indicated.
10 The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to automated external defibrillator annual servicing and updates the administrative site visit protocol as indicated.
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| 24-02930-175 | Deficiencies in Care at the Batavia Community Living Center Contributed to a Resident’s Death at the VA Western New York Healthcare System in Buffalo | Hotline Healthcare Inspection | ||
1 The VA Western New York Health Care System Executive Director ensures that community living center staff complete behavioral notes and conduct behavioral rounds, consistent with system policies regarding behavioral health and administration of antipsychotic medications, monitors for compliance, and takes action as indicated.
2 The VA Western New York Health Care System Executive Director evaluates community living center nursing staff compliance with system policies regarding the administration of medications, and nursing documentation related to medication refusals, medical provider notification, and residents’ nutritional intake, and takes action as required.
3 The VA Western New York Health Care System Executive Director reviews the system policy regarding the use of antipsychotic medications in the community living center and considers aligning system policy with Veterans Health Administration’s dementia system of care recommendation to document risk-benefit discussions for all residents receiving pharmacological interventions for dementia-related behaviors.
4 The VA Western New York Health Care System Executive Director makes certain community living center staff comply with the system policy on fingerstick blood sugar testing, including documenting results and notification to the resident’s provider, and monitors compliance, taking action as indicated.
5 The VA Western New York Health Care System Executive Director reviews Batavia community living center laboratory processes and takes action as necessary to ensure timely completion of orders.
6 The VA Western New York Health Care System Executive Director ensures community living center staff enter joint patient safety reports and disclosures, as Veterans Health Administration guides and requires, and in support of high reliability organization principles, and monitors compliance.
7 The VA Western New York Health Care System Executive Director makes certain the community living center quality assurance performance improvement procedures adhere to Veterans Health Administration requirements, including the use of data to track effectiveness of quality assurance activities, and supports improvement in community living center nursing care.
8 The VA Western New York Health Care System Executive Director ensures completion of the chief geriatric physician’s focused professional practice evaluation for cause per Veterans Health Administration requirements.
9 The VA Western New York Health Care System Executive Director evaluates community living center medical provider staffing to ensure staffing meets patient care needs and takes action as necessary, including continued recruitment to fill vacancies.
10 The VA Western New York Health Care System Executive Director ensures review of education plans, education needs assessments, and completion of a system dementia education plan as well as initial and ongoing Staff Training in Assisted Living Residences-VA training, as expected, for all community living center nursing staff, and takes action as indicated.
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